Experience of Conducting Sensitive Qualitative Research as a Cultural Outsider: Formulation of a Guide for Reflexivity

Sensitivity Lens

It is important to point out that the authors’ use of the term “sensitivity” does not conform to the gender stereotyping and stigmatizing of women as being emotional and sensitive (Plant et al., 2000). In this article, “sensitivity” includes anything that can generate anxiety and uneasiness in the participants, with potential negative consequences on the research. Participants may be unwilling to share their experiences, resulting in interviews that lack depth and do not adequately address the topics being explored. In sensitive research or topics, trust and rapport become difficult to achieve and the researcher–participant relationship can easily turn into one of concealment and deception (Lee & Renzetti, 1990). Research sensitivity may be situational and depends on the interaction between the researcher, participants and context of the study (Bahn & Weatherill, 2013; Brayda & Boyce, 2014; Tillman, 2002). Sensitivity issues may arise at different stages of the research process including the choice of topic, development of the interview guide and during interviews, if questions are asked which are viewed as inappropriate in the local culture. A research area may become sensitive, and thus evoke anxiety for the participant, because of how the discussion develops during the interview; therefore, sensitivity cannot be fully determined beforehand. For example, a discussion with health practitioners about service provision may result in disclosures of distressing experiences. Lee and Renzetti (1990) argue that “it is possible for any topic or research to be a sensitive one (p513).” However, some areas of research are more sensitive than others. These include studies that intrude into the private life of individuals, explore prohibited behavior, encroach on the interest of powerful individuals and involve topics sacred to those being studied that they do not wish to profane (Lee & Renzetti, 1990).

The breastfeeding study being considered in this article met Lee and Renzetti’s (1990) criteria for sensitive topics in a number of ways. First, the research intruded into personal experience as breastfeeding is a personal choice and a private journey (Charlick et al., 2019; Coomson & Aryeetey, 2018; Sheehan et al., 2019). In Hausa–Fulani culture, topics that relate to an object of female sexuality, for example, a woman’s breasts, are often only discussed in the private setting of a husband–wife relationship (Adamu, 2011; Pawlak, 2015). Second, the study indirectly explored the role of the mother-in-law, a powerful figure in Hausa–Fulani culture that exercises authority and has a strong influence on a mother’s choice to breastfeed (Joseph & Earland, 2019). There are potential risks associated with unstructured interactive interviews where the topic or context of the research might be considered sensitive because when participants tell their stories they are sharing personal and often intimate aspects of their lives. Tekada’s field experience researching female married participants as a male researcher highlighted how the researcher–participants’ gender mismatch intersected to create a sensitive environment that impacted the research process (Takeda, 2013). This was the case even though he shared language, culture, and ethnic identity with the participants.

Vulnerability Lens

Vulnerability is a state of an individual or a group, whose physical status, political, economic, social, or cultural environment limit their access to basic human needs and ability to make personal life choices (Liamputtong, 2007). Examples of individuals or groups whose circumstances make them vulnerable include children, ethnic minority groups and educationally and socioeconomically disadvantaged women living in rural communities (Dickson–Swift et al., 2009). Women from ethnic minorities living in rural communities or of low socioeconomic status are often less willing and able to participate in research due to their socioeconomic needs and heavy responsibilities (Edwards, 1990). Participants in the study under review fit into the description of vulnerability because the attitude towards Hausa–Fulani females emphasizes the perception that women are inferior to men; they are socioeconomically disenfranchised and in most matters must defer to the male (Afolayan, 2019). Conducting research with people who are considered vulnerable presents unique challenges and requires special attention from researchers (Liamputtong, 2007; von Benzon & van Blerk, 2017). Due to their lack of experience, novice researchers usually do not have the skills that are cultivated over time through regular fieldwork and reflexivity. This can result in them not being well prepared to deal with the challenges and responsibilities of conducting qualitative research involving vulnerable populations (Thummapol et al., 2019). If researchers do not adequately consider the research setting and culture of the community, their credibility and professional standing can be damaged. There is also the potential of further marginalizing participants (Liamputtong, 2007; Mccosker et al., 2001). For example, interviews covering areas considered to be private may result in emotional and psychological distress to the participants and their families (Shaw et al., 2020).

Cultural Identity Lens

Cultural identity refers to the characteristics that make an individual or a group unique and different from others; that sense of belonging based on one’s ancestry, cultural heritage, value, traditions, rituals, language, and religion (Song & Parker, 1995). Cultural awareness is the sensitivity to the similarities and differences that exist among different cultures and the use of this sensitivity in effective communication and relationships with members of another cultural group. To develop cultural awareness, the researcher needs to examine their professional and sociocultural background (Campinha–Bacote, 2002). In the setting of the study under review, religion plays a key role in the identity of Hausa–Fulani Muslim women, contributing to numerous physical, social, and economic restrictions, especially for those in rural communities. Studies have shown that researchers studying participants of other racial backgrounds experience challenges in gaining access to participants (Edwards, 1990; Riessman, 1987), leading to the suggestion of “ethnic matching” between the researcher and participants to avoid the difficulty in accessing participants (Rhodes, 1994). However, matching ethnicity or other elements of the identities of the researcher and the participants is not enough to create a common understanding and does not make the outsider researcher into an insider (Tinker & Armstrong, 2008). Matching elements of identity will not reduce the power differences between the two parties as power relations go beyond relative identities (Gunaratnam, 2003). The complex interplay of the different facets of identity determines the power balance in any situation. Törngren and Ngeh (2017) showed how the power dynamics between participants and researchers changed during interviews, depending on the participants’ perception of the researcher’s race and ethnicity in relation to the discussion topic and other facets of identity such as age, gender, and class.

Song and Parker (1995) noted that while sharing racial identity with the research participants will help the researcher to gain access, it is insufficient to build interview rapport and disclosure; hence, the point of connectivity between the researcher and participants needs to be developed, irrespective of whether the researcher is considered an insider or outsider. Building a cross-cultural relationship requires the researcher to develop cultural competence in the form of pre-requisite knowledge and skills (Davis, 2020). Cultural competence is a process, rather than an end point, and begins when researchers explore and self-critique their sociocultural and professional background including recognizing their biases and assumptions about individuals who are different to themselves (Campinha–Bacote, 2002). Campinha–Bacote (2002) posited that self-awareness may prevent the researcher’s bias from impeding their interaction with individuals of other cultures or ethnic groups. Strategies to self-awareness include the researcher discussing their experience with other people and self-reflexivity (Hughes Fong et al., 2016). Cultural awareness and knowledge about the research setting set the stage for developing and implementing research that is sensitive to potential cultural differences (Vandenberghe, 2008).

Reflexive Questions

This section highlights critical questions to assist novice researchers to reflect, anticipate and resolve some of the issues that arise when conducting qualitative studies as an outsider. A critical analysis of the researcher and participants’ social identity through the sensitivity, vulnerability, and cultural identity lenses requires asking the appropriate questions before and during the study. These questions (see Table 1) were inductively derived from the literature review and the first author’s previous experience of working with the Hausa–Fulani community and his reflexivity diary of self-questioning before and during the study. Researchers may use the list of questions in different ways. For some it may simply act as a prompt, to highlight issues that need to be considered and explored. Novice researchers are likely to benefit from using a more structured approach, beginning with a desk review of other relevant studies and reports. This may enable the researcher to modify or remove some irrelevant questions or add questions. They may also be able to answer or partially answer some questions before deciding how to address the remaining questions, for example, through talking to government or non-government organization (NGO) personnel or other researchers working in the area.

Overview of the Development and Use of the Tool

The Guide for Reflexivity used by the authors comprised the three main elements shown in Figure 1. The authors’ experience of conducting their research and reflecting on the study have enabled them to further develop the tool, particularly in terms of integrating the components and refining and adding to the list of questions. Using the guide for the study under review was found to be particularly valuable on two counts. Firstly, the social identity mapping ensured that all facets of identity were considered when reflecting on positionality and how it may influence the research study. Secondly, the questions enabled the researchers to identify and scrutinize, in a structured way, important issues which needed to be considered when planning their research. Examples of questions that the authors had to address during the study have been included in the sections below (shown in italic) to illustrate how the authors used the questions in Table 1 and how novice researchers may similarly be able to use the reflexive questions in their own research.

Positionality

Self-representations and positionalities of researchers can stir up stereotypes that influence the feelings and views of the participants (Mullings, 1999). The first author (FJ) is a Nigerian male medical doctor with substantial experience of working with ethnic Hausa–Fulani rural communities but no language, religious and cultural affiliation with the study population. The use of the Guide for Reflexivity started with FJ mapping his own and the participants’ identities including socio-demographic factors, educational background, ethnicity, religion, and language. Following the mapping process, FJ needed to consider what facets of the researcher’s and participants’ identities are most significant in the ongoing research? It was only by reflexively considering the identities of both the researcher and participants that it was possible to appreciate the extent of the power differences and the potential impact of his male identity on the research. FJ grew up in a hegemonic masculinity society similar to the one in the research setting. He recognized that there is the potential for male novice researchers to use societally imposed gender inequalities to their advantage and further marginalize the participants’ autonomy and voluntary participation. Reflexively questioning the intention behind the researcher’s actions will help ensure that the participants’ right to autonomy is upheld. For example, keeping a journal of key moments and critical reviews from peers, which is especially important for a novice researcher, will ensure that researchers remain reflexive throughout the research process.

Accessing the Research Setting

Gaining access to a research site can be especially challenging as a cultural outsider researcher (Singh & Wassenaar, 2016). The first author, drawing from his professional experience of working with similar communities in North-West Nigeria, used the reflexive question list to help identify issues that needed to be considered. For instance, as a male researcher who was to interview married female participants, he was interested in knowing how the local society defines gender relations and what ways it may affect access to the research sites and participants (How does the researcher’s identity influence the cultural expectation of the participants and the host community?). The practice of “kulle” in Hausa–Fulani culture demonstrates how gender influences physical access to some settings. Male strangers are usually barred from entering homes where there are married women (Afolayan, 2019). It was important to be aware of this and other cultural beliefs when making arrangements to approach potential participants and planning the interviews.

Gatekeepers are critical to accessing the research site in many communities and therefore the researchers needed to address the questions what is the protocol for community entry; does it require permission from a gatekeeper to approach potential participants? For the study under review, the role of the gatekeepers was more than simply allowing access to the research setting; they also ensured that the researchers and research methods were respectful of local culture. Access to the health facilities where recruitment took place was arranged through a courtesy visit to the Director of Primary Health Care based in each of the local government areas. The first author used this visit to ask questions such as what are the participants’ and the community’s experience of qualitative research? This visit was vital as it provided answers to this and other questions and guided the researchers to the heads of the primary health care centers situated in the recruitment sites. Careful preparation before commencing fieldwork is particularly important for inexperienced researchers as an error (for example, approaching the wrong person) could jeopardize the use of that research site.

Researchers agree that gaining access can be facilitated by building positive relationships with gatekeepers (Singh & Wassenaar, 2016; Wanat, 2008). In this study, the gatekeepers ensured that the researchers gained access to the health facilities but did not determine who was recruited into the study. Where gatekeepers are used in recruiting participants, they can wield great influence, with potential ethical issues (Devers & Frankel, 2000). The authors recognized that gatekeepers could influence the success of the research. Therefore, the purpose of the study and how it was to be conducted, as well as any potential benefits to the participants and community, were made clear. The researchers maintained regular communication with the gatekeepers during the study.

Accessing the Research Participants

Recruiting participants is a challenging process and requires the researcher’s communication and negotiation skills to build rapport and mutual respect, especially when undertaking research with socioeconomically and educationally disadvantaged participants (Devers & Frankel, 2000; Liamputtong, 2007). In the research setting, rapport is a stage in social interaction where there is a feeling of trust and sincerity between parties. For the novice researcher, achieving rapport is a process that builds on the researcher’s contextual awareness, social information gathering and interpersonal competencies (Jihong et al., 2020). For example, in the research community under review, exchanging greetings is an essential step in establishing non-threatening contact and rapport. In Hausa greetings, a person wants to know everything about one’s situation because of the feeling that whatever affects that person also affects him (Chamo, 2015). Usually, first impressions matter; therefore, the first author and interpreter (MA) were patient, listened and showed sympathy towards the women they approached and their immediate situation. It was important that the participants were provided with sufficient information to enable them to decide whether to take part in the study (Are participants able to make an informed decision on whether to consent to take part?). Strategies used included the use of a bilingual female interpreter, a participant information sheet which was read out and discussed in the local language with each potential participant by MA, and culturally sensitive private face-to-face meetings during Mother and Child Health clinics. The researchers were mindful that potential participants were unlikely to be able to understand English or to read, although others in their household may have been literate. Information was provided on the research verbally and in writing using lay terms, printed in both English and the local language. Participants were given adequate time (2 weeks) to reflect on the information and were told that it is their right to refuse to participate or to withdraw from the study at any time. Verbal consent was given by each participant when the interviews were arranged. Prior to each interview, the informed consent form was explained, questions invited, and the participant either thumb printed or signed it.

It was important to reflect on what steps needed to be taken during recruitment and the interviews to ensure that the first author and interpreter were accepted within the community. In establishing cultural trust, FJ and MA ensured that their behavior and activities were respectful and conformed with local cultural values. For example, their outfits were reflective of dressing and communication etiquette unique to the local community. A researcher’s outfit may demonstrate their religious or moral values, and can make a difference in whether or not requests for interviews will be granted (Takeda, 2013). Novice researchers similarly need to ensure that their behavior (for example, dress, language, and conduct) is always respectful of local cultural values.

Using Interpreters

Interpreters are viewed as active producers of knowledge; therefore, their competencies, perspectives and social location should be considered (Berman & Tyyskä, 2011). The interpreter (MA) is a female Muslim teacher and married, with no children. She had no personal experience of breastfeeding. She has an undergraduate degree and had previously worked in the researched community in a similar capacity with international NGOs. MA has a good grasp of the social setting because of her shared ethnic and religious background which, with her gender, was key in the mediation between the researcher and the participants. Participants were observed to be relaxed, comfortable and open to discussion with the interpreter. Novice researchers can learn from working with an experienced interpreter, especially if from the local area. Even if an interpreter is not required, in communities where cultural practices prevent male researchers from freely conversing with women, being accompanied by a well-respected female can facilitate access to the community and the participants.

During the pilot study, the interpreter was initially reluctant to probe some of the responses, due to her familiarity with the community. However, FJ’s outsider position compelled him to scrutinize certain issues more closely, instead of accepting all the interpreter’s feedback, as suggested by Suwankhong and Liamputtong (2015). The experience in this study demonstrated the value of co-interviewing as a mechanism to blunt the influence of the insider and outsider in research with cultural and gender divides (Redman–MacLaren et al., 2014).

Interview Protocol and Process

In qualitative studies, interviews are an integral part of understanding the perspectives of others (Ritchie & Lewis, 2003). The development of good interview questions requires that the researcher understands the cultural context and workability of the interview protocol. People’s lives have “worth” and a researcher wants to approach inquiring into their lives with sensitivity. Two pilot interviews were held with mothers in the research setting, to explore how the interview questions fared with the participants. It is important that transcripts of pilot interviews conducted by novice researchers are peer review by an experienced researcher, as occurred in the present study. This will enable the sensitivity and cultural appropriateness of the open-ended questions to be appraised, as well as their adequacy to generate answers to the broad research question.

The venue and the seating arrangement during the interview, which took a cue from what is usual in the community, was also key to creating rapport. The first author ensured privacy and paid attention to the physical arrangements of the interview. The participant and interpreter sat on one side of the table facing each other and making eye contact, while FJ sat alone on the other side of the table away from them but close enough to hear.

As anticipated, the gender relation norm played out in the interview process. Usually, female–female interaction in a public space is without restriction. In contrast, the male–female interaction is defined and limited by a cultural expectation for women called the feeling of “kunya." “Kunya” is translated as shame in the English language but does not necessarily convey the same meaning as the English translation. Women display “kunya” when interacting with a male by keeping a distance, lowering their gaze towards the ground, avoiding eye contact, sometimes refraining from talking, or affirming with a single syllable word “yes” (Adamu, 2011; Pawlak, 2015; Will, 2016). In the study under review, younger mothers were the least forthcoming, resulting in more time being required to build rapport with them as participants. Generally, participants appeared to be most emotional when responding to questions about their experience of labor, delivery and the few hours after delivery. Following the first few interviews, FJ and MA reflected on the reaction of participants to the interview topics in order to address the question what are the points of potential sensitivity? Although they had expected that some mothers would be embarrassed when talking about the breast, especially in the presence of a male, the emotional reactions to discussions about giving birth were unexpected. The interviewers were sensitive to the participants’ non-verbal gestures, for example, facial expressions and physical posture and tried to make the mothers feel at ease as much as possible. As well as responding to verbal responses during interviews, novice researchers need to be aware of non-verbal gestures which indicate that participants are experiencing discomfort or distress. If a participant does appear to be distressed or tired, it may be that a break is needed or that the participant wishes to discontinue the interview.

Table 2 brings together the strategies used by the researchers. Notes for other researchers working as an outsider, which are applicable to other research studies and settings, have been included.

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Table 2.

Summary of Strategies Used.

Tasks/Situation to be Addressed	Strategies Used by Authors	Notes for Other Researchers
Consideration of positionalities of researchers and participants	Mapping the social identities of the researchers and participants	The social identity of participants can be mapped using available written information and speaking to key people working and living in the community, as well as other researchers who have worked in the area
	Being reflexive about the influence of the identities of the researchers and participants on the research process	Novice researchers must address the need for reflexivity early in the research process and remain reflexive throughout the study
	Keeping a research diary and critical review from peers	Support from more experienced researchers is important, especially for those who are less experienced
Learning about the study context and participants	Review of relevant studies and reports	Reports by government and NGOs may be unavailable online, so the researcher may need to contact agencies
	Discussions with key people working in the study area	Being knowledgeable about the local community, including cultural practices and values, is important for all aspects of the research process
Entering the community and gaining acceptance	Identifying gatekeepers and other contacts	Start by contacting key government officers (who are generally respected by the community) working in the area such as health staff and headteachers. They may be able to answer questions and act as a gatekeeper, as well as identifying and introducing you to other contacts (for example, community leaders and leaders of religious and women’s groups)
	Building relationships with gatekeepers and community members	Needs to start early; several visits will be required before the research commences
	Ensuring that the researchers’ behavior conforms to local cultural values	The outfits worn by researchers when visiting or working/staying in the research area should adhere to local cultural and religious practices. Language and conduct should show respect, for example, not eating prohibited foods or drinks
Gaining informed consent from the participants	Writing an information sheet in lay terms to read out and discuss in the local language	The ethics committee will require adequate information to be prepared for potential volunteers. The process for recruiting participants will need to be described step-by-step so that it is clear that there will be no coercion
	Culturally sensitive face-to-face meetings between each potential participant and the researchers	In many cultures, it is normal for people in the community to be present during community activities and to listen to what is going on. However, potential participants may be asked personal questions and have a right to confidentiality. Therefore, meetings and interviews must take place in a private setting
Participants being illiterate	Use of a female interpreter; providing adequate information verbally and answering questions, in the local language	Members of the study group may not be able to read the local language so there must be someone present, with the researcher, who can converse with potential participants about the study. An experienced interpreter can provide valuable support for the novice researcher
Ensuring that the interview venue and seating arrangements are appropriate	Holding interviews in a room to ensure privacy. Arranging seats to take account of logistical issues, such as recording the interview, as well as gender relationships	The seating and spatial arrangements should conform to what is normal in that community. Having a table between the researcher and participant is usually not conducive to an open, relaxed discussion
Considering the well-being of participants	Checking that the participant is comfortable at regular intervals during the interview	The physical comfort of the participant, who may have an infant or child with her, is of paramount importance. Where possible refreshments should be provided by the researcher
	Responding to verbal responses and non-verbal cues	Novice researchers need to be aware of non-verbal gestures which indicate that participants are experiencing discomfort or distress
Addressing the sensitivity of the topic	Being aware of the reasons why the topic area is considered sensitive	Knowing why the topic area is sensitive enables the researcher to avoid or minimize the use of words which evoke emotions and to conduct interviews more sensitively
	Phrasing questions and guiding the discussion during the interviews to lessen the potential sensitivity	Being very familiar with the interview guide will help the researcher to fully focus on the participant and the discussion, to identify potential sensitivity issues